Process Group
Claims Management
Objective
Facilitate timely resolution through secondary review of adjudicated claims which parties (e.g., beneficiary and insurance provider OR provider and insurance provider) do not agree .
Input
- Claim identifier
- Beneficiary identifier
- Provider identifier
- Claim information (e.g., encounter date, claim number) Dispute notes
Output
- Change claim status to dispute
- Input into possible policy change
- Advice to claim office ―factory‖ on how to deal with type of claim in future
- Amount approved for claim
- Claim identified for reprocessing
- Financial transaction to GL (e.g., accounts receivable/payable) Case referred to arbitration